Provider Demographics
NPI:1467712448
Name:PEETHUMNONGSIN, ERICA SOPAH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:SOPAH
Last Name:PEETHUMNONGSIN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:800-782-6945
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-684-5537
Practice Address - Fax:919-681-8521
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD79604207P00000X
NC2016-01349207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program